Remote Claims Review Nurse Job Description

Introduction: Make an Impact from Anywhere

Are you a detail-driven nursing professional with a passion for quality care and administrative excellence? Take charge of your future by stepping into a pivotal role as a Remote Claims Review Nurse. In this opportunity, you’ll play a significant part in transforming healthcare operations by ensuring claims are processed accurately, fairly, and efficiently—all from the comfort of your home.

This role is more than just checking boxes. It’s about safeguarding care quality, supporting patients behind the scenes, and driving innovation in healthcare claims management. Join a mission-led team where your clinical expertise meets analytical rigor, helping reshape how healthcare payers and providers interact.

Key Responsibilities: Your Role in Driving Excellence

As a Remote Claims Review Nurse, you will bring your clinical judgment, nursing knowledge, and communication skills to support critical functions in healthcare operations. Expect to:

• Evaluate complex medical claims to determine medical necessity, service appropriateness, and compliance with policies.
• Apply evidence-based guidelines and established criteria (such as MCG or InterQual) during the review process.
• Collaborate with physicians, case managers, and billing specialists to clarify medical information and ensure alignment with clinical standards.
• Prepare detailed summaries and rationale for claim approvals, modifications, or denials.
• Maintain meticulous documentation of findings in secure digital systems.
• Flag trends or patterns of improper claims for internal audit or training purposes.
• Ensure timely turnaround to meet service level agreements and regulatory requirements.
• Contribute to process improvement initiatives by identifying bottlenecks or inconsistencies.

Work Environment: Empowered Remote Work

Experience the flexibility of fully remote nursing work without sacrificing impact. Our digital tools and supportive structure ensure you stay connected, informed, and empowered, no matter where you live. Your home office becomes your command center for managing claims and making data-backed decisions that improve care quality.

You'll be part of a diverse, multi-state team of healthcare professionals who collaborate virtually through secure platforms and regular check-ins. Autonomy, trust, and communication form the foundation of your remote experience.

Tools & Technology: Smart, Streamlined Systems

To help you succeed, we equip you with cutting-edge software and platforms that simplify and streamline your work, including:

• Secure Electronic Health Record (EHR) and claim review systems
• Clinical decision support tools (e.g., MCG, InterQual)
• Internal communication platforms like Microsoft Teams or Slack
• Performance dashboards and quality assurance trackers

You’ll have access to ongoing technical support and virtual onboarding to ensure you feel confident in every task.

Qualifications: Your Clinical Expertise, Reimagined

We’re seeking a seasoned healthcare professional who brings more than credentials—you get insight, compassion, and dedication to healthcare improvement.

Required:

• Active RN license (multi-state or compact preferred)
• At least three years of hands-on experience in a clinical nursing setting (hospital, home health, or case management preferred)
• At least 1 year of experience in medical claims review, utilization management, or insurance-based nursing roles
• Firm grasp of healthcare coding, medical terminology, and reimbursement structures
• Proficient in electronic documentation and secure data management

Preferred:

• Familiarity with CMS guidelines, HEDIS measures, or state/federal regulatory standards
• Prior experience with appeals and denials workflows
• A nursing degree at the bachelor's level or above
• Experience in telehealth or digital health environments

Personal Attributes: What Sets You Apart

We’re looking for someone who thrives on precision, critical thinking, and problem-solving. Ideal candidates will be:

• Excellent communicators, especially in written formats
• Emotionally intelligent with a calm, professional demeanor
• Detail-oriented with a high level of accuracy
• Tech-savvy and eager to learn new systems
• Adaptable and independent while staying collaborative in a virtual team

Compensation and Benefits: Valuing Your Time and Talent

Enjoy a competitive annual salary of $89,949 and a benefits package designed to support both your personal well-being and professional development.

Perks Include:

• Flexible scheduling and location independence
• Health, dental, and vision insurance
• Generous PTO and paid holidays
• Professional development stipends
• Virtual wellness programs and mental health support
• Retirement savings plan with employer matching

Growth Opportunities: Expand Your Impact

As the healthcare industry evolves, so do we. This role offers multiple avenues for professional advancement, including:

• Leadership pathways into utilization management, compliance, or quality assurance
• Special project involvement with analytics and strategy teams
• Continuing education reimbursement to support certifications (e.g., CCM, CHCQM)
• Cross-training in healthcare auditing or risk adjustment review

Why Join Us: A Mission That Matters

We are a forward-thinking healthcare organization focused on innovation, transparency, and patient-centered outcomes. By joining our remote nursing operations, you contribute to a healthier future while gaining balance in your own life. Our culture is rooted in purpose and progress—you’re not just a part of the process, you’re driving transformation from the inside out.

Ready to Apply? Your Next Big Opportunity Awaits

This is your moment to transform clinical experience into strategic healthcare impact, from wherever you are. If you're ready to blend your nursing background with data-driven precision and help improve claims processing across the industry, we want to hear from you.

Your next big opportunity awaits—apply now!